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Justification of intervention for limb-threatening ischemia: a surgical decision analysis
T E Brothers1, G A Rios, J G Robison
1Department of Surgery, Medical University of South Carolina and Ralph Henry Johnson Department of Veterans Affairs Medical Center, Charleston 29425, USA. brothete@musc.edu
Insights
Revascularization offers improved outcomes for elderly patients with critical limb ischemia. This intervention is cost-effective, providing better quality-adjusted life-years compared to amputation or expectant management.
Area of Science:
- Vascular Surgery
- Health Economics
- Geriatric Medicine
Background:
- Elderly patients with distal lower extremity vascular occlusive disease face limited treatment options.
- Declining medical resources necessitate careful evaluation of intervention costs and benefits.
Purpose of the Study:
- To compare revascularization, amputation, and expectant management for distal lower extremity vascular occlusive disease in the elderly.
- To assess the cost-effectiveness of revascularization using quality-adjusted life-years (QALYs).
Main Methods:
- Surgical decision analysis was employed to evaluate three treatment strategies.
- Outcome probabilities were based on revascularization experience, and utility scores were derived from patient assessments.
- Cost-effectiveness was analyzed by comparing QALY gains across treatment options.
Main Results:
- Revascularization is predicted to yield 1.10 QALYs more than amputation and 1.16 QALYs more than expectant management.
- The cost per QALY for revascularization is $5,280 more than expectant management but $33,900 less than amputation.
- Sensitivity analysis indicates revascularization is the most cost-effective strategy if 1-month patency rates exceed 11%.
Conclusions:
- Revascularization is a justified and cost-effective intervention for limb-threatening ischemia in the distal lower extremity of the elderly.
- This approach offers superior patient outcomes and reasonable costs, especially when patency rates are maintained.
Abstract:
Intervention for vascular occlusive disease of the distal lower extremity in elderly patients will inevitably be scrutinized as medical resources decline. The authors applied surgical decision analysis to three treatment options: revascularization, amputation and expectant management. The appropriate outcome probabilities were derived from our experience with revascularization to the tibial and pedal vessels, and utility scores were obtained by formalized patient assessment. Revascularization was predicted to improve patient outcome by 1.10 quality-adjusted life-years compared with primary amputation and by 1.16 quality-adjusted life-years compared with expectant management. To gain one additional quality-adjusted life-years, revascularization would cost $5280 more than expectant management, but $33,900 less than primary amputation. Sensitivity analysis predicted revascularization to be the least costly treatment per quality-adjusted life-years as long as 1-month patency exceeds 11%. Revascularization for limb-threatening ischemia of the distal lower extremity is justified and can be performed at a reasonable cost.